Philosophy of Psychiatry

An emergency room is not a place of calm. An unremitting cacophony of monitors chirp and an orchestra of howling, coughing, and emesis fills the air, to which swirling physicians serve as its conductor. Amidst this storm can reside a hurricane: the 'psych patient.' Conventional moral judgments and preeminent theories of morality hinge on tangential alternatives and options. Thus, moral condemnations are calls for alternative action. However, as this piece argues, the restraint of patients in psychiatric emergencies are situations of (...) no other alternatives and therefore, standing moral debates and judgments lack sufficient strength given the lack of options. (shrink)

This thesis investigates the nature of psychiatric disorders, and to what extent they can form a basis for classification, explanation, and treatment interventions. These questions are important in the light of the “crisis of validity” in psychiatry, according to which current diagnostic categories do not pick out real disorders. I address the questions by defending an account of psychiatric disorders that can better accommodate social aspects and non-epistemic values than the symptom-based model of the Diagnostic and Statistical Manual of Mental (...) Disorders (DSM) and the brain disease model of the biomedical approach, including the Research Domain Criteria (RDoC). I concentrate on three ways that psychiatric disorders can differ from prototypical natural kinds, such as biological species and chemical elements. First, the concept of psychiatric disorder or mental disorder is partly value-laden and cannot be defined based only on scientific facts. Second, the objects of psychiatric classifications are interactive human kinds because people with disorders respond to their classifications through looping effects. Third, sociocultural factors can shape disorders in complex ways, which is indicated by their cross-cultural variation. I argue that these challenges can be overcome with a pluralistic explanatory account that grants an explicit role to value-sensitive considerations and social scientific research. Based on this, I argue that particular disorders can in principle support inductive inferences. ------------------------------------------------------------------------------------------ My key argument is that although whether a condition is considered pathological is partly a value-laden question, this does not rule out a realist account of particular psychiatric disorders as homeostatic property cluster kinds (HPC). I assert that causal mechanisms responsible for psychiatric kinds can be understood non-metaphysically based on the contrastive-counterfactual and interventionist theories of explanation. An advantage of this account is that it can address the concern that psychiatric explanations require one to relate heterogeneous causal factors on different levels, such as genetic, neurological, psychological, and social. My novel argument is that mechanistic explanations of scientific kinds have applicability domains over which they account for specific aspects of kinds and warrant inductive inferences. That is, identifying the applicability domain of an explanation spells out the conditions under which the explanation is expected to be reliable and when it can break down. This helps to understand how different discipline approaches, including social and cultural ones, can be complementary and make an explanation of a psychiatric kind more reliable. On the other hand, the account also shows how the complex nature of psychiatric kinds can license re-classifications for different epistemic and non-epistemic purposes. Finally, in the light of the social implications of psychiatric classifications, I suggest a value-sensitive or ameliorative approach to engineering the concept of psychiatric disorder. In conclusion, my account shows that research on the social and cultural factors that shape psychiatric disorders, and weighing the non-epistemic values that influence classificatory practices, can and should inform classificatory choices as well as policy and treatment interventions. (shrink)

In this chapter, we explain how Karl Jaspers’ concept of empathy can be expanded by drawing upon the tradition of philosophical phenomenology. In the first section, we offer an account of Jaspers' concepts of empathy and incomprehensibility as he develops them in General Psychopathology and “The Phenomenological Approach in Psychopathology.” In the second section, we survey the recent literature on overcoming Jaspers' notion of incomprehensibility and expanding his concept of empathy. In the third section, we outline the levels of investigation (...) at which phenomenological inquiries into psychopathology may proceed. These levels of human existence are, in descending order of depth, (1) phenomenal experiences, (2) interpretive frameworks, (3) modes of existence, and (4) existentials. In the fourth and final section, we argue that to fully empathically comprehend patients with schizophrenia and other mental disorders, the possibility of alterations at all four levels of existence must be acknowledged. (shrink)

Se le llama ‘psiquiatría biológica’ a la vertiente de la investigación psiquiátrica que busca establecer asociaciones estables entre condiciones psiquiátricas y factores biológicos específicos. La búsqueda de tales asociaciones está motivada por lo que llamo el “compromiso causal” de la psiquiatría biológica, que es la presunción de que factores biológicos específicos son las causas principales de las condiciones psiquiátricas. En este artículo argüiré que dicho compromiso es una presunción implausible sobre esas condiciones, pues la mejor evidencia psiquiátrico-biológica disponible no lo (...) respalda y es dudoso que la evidencia futura lo hará. (shrink)

If a patient complies voluntarily with a certain proposal, we generally regard the treatment as legitimate. But a competent patient may also assent to a certain treatment only because he was compelled to do so. Influences on the formation of his decision may render his choice contrary to his will. It is my aim to focus on these particular forms of coercion which are often neglected in discussions of informed consent.

While research on Attention Deficit Hyperactivity Disorder (ADHD) has traditionally focused on cognitive and behavioral deficits, there is increasing interest in exploring possible resources associated with the disorder. In this paper, we argue that the attention-patterns associated with ADHD can be understood as expressing an alternative style of inquiry, or “zetetic” style, characterized mainly by a lower barrier for becoming curious and engaging in inquiry, and a weaker disposition to regulate curiosity in response to the cognitive and practical costs associated (...) with inquiry. Exploring this zetetic style from an epistemological perspective, we show that it is often epistemically rational and can be advantageous in important respects. We close by suggesting that the very aspects of the zetetic style that might at times render it disadvantageous from the point of view of individual subjects with ADHD, will often confer epistemic benefits to the social group that the subjects are part of. (shrink)

In their thought-provoking article, Sedlakova and Trachsel (2023) defend the view that the status—both epistemic and ethical—of Conversational Artificial Intelligence (CAI) used in psychotherapy is complicated. While therapeutic CAI seems to be more than a mere tool implementing particular therapeutic techniques, it falls short of being a “digital therapist.” One of the main arguments supporting the latter claim is that even though “the interaction with CAI happens in the course of conversation… the conversation is profoundly different from a conversation with (...) a human therapist” (Sedlakova and Trachsel 2023, 8). In particular, unlike a human therapist, CAI cannot help its users gain new insight and self-understanding (Sedlakova and Trachsel 2023). We agree that currently available therapeutic CAI cannot be considered a “digital therapist,” however, we think that the issue surrounding the acquisition of new self-understanding in the interaction with therapeutic CAI is more complicated than Sedlakova and Trachsel suggest. (shrink)

Group therapies possess a great number of benefits for trauma survivors, yet there exists a lack of clarity in the literature surrounding the application of trauma principles in group settings, or an awareness of the role of mindfulness-embodiment technologies for resourcing individuals prior to trauma processing. This article explores the value of structured-format auxiliary groups for trauma treatments that orient towards resourcing participants. We utilise the example of mindfulness and embodiment-based resourcing technologies, as illustrative of top-down and bottom-up approaches to (...) trauma resourcing. It is demonstrated that these technologies cultivate the ability to orient attention towards the present moment, increasing bodily and affective self-awareness, which serves to reduce patterns of reactivity, thereby supporting: symptom stabilisation; improved reflective and mentalising ability; and the cultivation of the self- and co-regulatory capacities necessary for trauma-processing group work. An overview of best-practice principles for establishing auxiliary resource groups is then provided, outlining: the phasic introduction of these resources in ‘group settings’ when and where they are applicable; the necessary screening requirements and exclusion criteria; the role and function of group norming and relational approaches; the importance of pendulation and titrations principles; and how to work with distinct populations and in-group heterogeneity. In this way this article elucidates the foundations for both developing an auxiliary resourcing group and for implementing such groups into a treatment plan for individuals living with trauma. (shrink)

This paper argues that the crucial feature of the drug-related desires experienced by addicted agents is not that they ‘push’ the agent with a force she cannot oppose, but that they are not easily undermined by things that normally have the ability to undermine desires —in other words, that they are extraordinarily recalcitrant. As a result, the disposition to experience these desires is very persistent over the long-term, manifesting itself in particular episodes of wanting to use drugs that recur with (...) great frequency. Both the persistence and the recurrence of these desires, it is argued, contribute to a diminished ability to respond to relevant reasons that speak against drug use. (shrink)

Characterizations of autism include multiple references to rigid or inflexible features, but the notion of rigidity itself has received little systematic discussion. In this paper we shed some light on the notion of rigidity in autism by identifying different facets of this phenomenon as discussed in the literature, such as fixed interests, insistence on sameness, inflexible adherence to routines, black-and-white mentality, intolerance of uncertainty, ritualized patterns of verbal and non-verbal behavior, literalism, and discomfort with change. Rigidity is typically approached in (...) a disjointed fashion (i.e., facet by facet), although there are recent attempts at providing unifying explanations. Some of these attempts assume that the rigidity facets mainly relate to executive functioning: although such an approach is intuitively persuasive, we argue that there are equally plausible alternative explanations. We conclude by calling for more research on the different facets of rigidity and on how they cluster together in the autistic population, while suggesting some ways in which intervention could benefit from a finer-grained view of rigidity. (shrink)

Autism spectrum disorder (ASD) is a psychopathological condition characterized by persistent deficits in social interaction and communication, and restricted, repetitive patterns of behavior and interests. To build an ecological-enactive account of autism, I propose we should endorse the affordance-based approach of the skilled intentionality framework (SIF). In SIF, embodied cognition is understood as skilled engagement with affordances in the sociomaterial environment of the ecological niche by which an individual tends toward the optimal grip. The human econiche offers a whole landscape (...) of affordances, and situated individuals respond to a field of relevant affordances. An important part of SIF is an ecological-enactive interpretation of the free energy principle and predictive processing. Predictive processing accounts indicate that in ASD too much precision is assigned to prediction errors. Autistic persons depend heavily on current sensory information and less on prior beliefs and cannot attune to stable regularities. To reduce uncertainty, they over-rely on routines, strict habits, and a familiar environment—a predictable ecological niche they construct. I argue that skilled intentionality gives us the framework from which to analyze the autistic field of affordances. Autistic patterns of affordance-related bodily states of action readiness are only sensitive to very specific solicitations in the environment and achieve optimal grip in well-known situations. Autism is to be understood as a disorder of bodily normativity. Taking this approach helps us figure out what neurotypical people can do to attune their environment in order to scaffold the needs of autistic individuals by redesigning the landscape of affordances. (shrink)

In contemporary philosophy of mind and psychiatry, schizophrenic thought insertion is often used as a validating or invalidating counterexample in various theories about how we experience ourselves. Recent work has taken cases of thought insertion to provide an invalidating counterexample to the Humean denial of self-experience, arguing that deficiencies of agency in thought insertion suggest that we normally experience ourselves as the agent of our thoughts. In this paper, I argue that appealing to a breakdown in the sense of agency (...) to explain thought insertion is problematic, and that rather than following the prevailing binary approach which holds that certain features of consciousness go missing while others remain wholly intact, a better explanation involves construing thought insertion as a disturbing or disrupting of the subjectivity (for-me-ness) of experience. The result is that experiencing ourselves as the subject of our thoughts is where future research should be directed, given the robust persistence of this form of self-experience across psychopathological and non-psychopathological cases alike. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Standards and Assumptions, the Limits of Inclusion, and Pluralism in PsychiatryBennett Knox*, MA (bio)Let me begin by expressing my gratitude to AAPP, PPP, and the Jaspers Award Committee—I am deeply honored to receive this award. So too let me thank Anke Bueter (2022) and Awais Aftab (2022) for their thought-provoking commentaries. Many of the concerns they bring up are ones that I share, so I am delighted to have (...) a chance to discuss them in my response. I will bring up three central issues in turn: 1) the role of shared standards versus background assumptions, 2) the limits of inclusion, and 3) pluralism in psychiatry.Shared Standards or Background Assumptions?Both Bueter and Aftab reference Longino's "shared public standards" criterion for social objectivity (1990, p. 77; 2002, p. 130), which I did not explicitly discuss in the original paper (Knox, 2022). This was a choice I made partly because in the case of psychiatry determining what constitutes an appropriate "shared public standard" is often not at all straightforward, which points to a potential problem for Longino's view. Namely, in some cases it is a matter of dispute whether some assumption shared within a scientific field should be counted as a "shared public standard" (which Longino requires that there be) or a "background assumption" (which she requires be subjected to critical scrutiny). And it is sometimes unclear how we could effectively adjudicate this type of disagreement.Take the example Bueter uses of "psychiatrists aiming for biomedical explanations of a particular mental disorder, whereas the critics value research that does not assume the existence of mental disorders" (2022, p. 273). A conflict along these lines often does arise between advocates of the pathology paradigm and the neurodiversity paradigm with regard to Autism, for example.1 A psychiatrist working within the pathology paradigm may argue that something like "psychiatry must deal only with mental disorders, understood as pathologies" constitutes a shared standard, and so psychiatric research on Autism must understand it as a pathology. An advocate of the neurodiversity paradigm, however, might argue that this same proposition [End Page 275] is merely a normative background assumption shared among many psychiatrists, which ought to be questioned and ultimately rejected. How might we adjudicate this meta-disagreement about the status of this standard/assumption?Bueter gives some helpful guidance on this issue by pointing to Carrier's requirement that participants exhibit the "epistemic attitude" (2013). I agree that if all participants commit themselves to this attitude, then "…differences in conceptual resources and standards of assessment need not make shared deliberation impossible, and the standards can be a subject of discussion themselves" (Bueter 2022, p. 273). For instance, since this attitude requires some commitment to empirical adequacy, we might search for some empirical evidence that favors one paradigm over the other. But advocates of both paradigms might actually agree on all the empirical facts, and yet still have a deep disagreement about which paradigm's understanding should be accepted as a shared standard. If participants are committed to some common standards and goals, we may often be able to resolve this sort of problem. But there is still a danger that we may arrive at an impasse, with no clear idea how to proceed.Though in many cases scientific experts must be allowed some power to set the standards in their domain (lest we dilute that expertise in ways that Aftab rightly points out would be problematic), I would also caution against accepting that something is a legitimate shared public standard just because the members of a scientific community say so. In keeping with the spirit of Longino's reliance on Quine, none of our shared standards are in principle immune from revision—save perhaps a minimal commitment to empirical evidence and rational argument.The Limits of InclusionMy impression is that Longino's response to the "Nazi problem" presented by Hicks (2011) might be to bite the bullet: her account does require allowing Nazi scientists to participate, and perhaps even cultivating their participation. But if (as seems likely) the Nazi shows themself to be unable to adhere to the shared standards... (shrink)

Social ontology focuses on questions about the reality of human categories. The typical examples are gender and race. Common questions about them are: Do they exist? What is their nature? Do they exist in the best possible way? Meanwhile, the philosophy of psychiatry has been discussing the reality of psychopathology, what is the best way to classify mental disorders, and whether it is possible to define them without normative vocabulary. I think there is something not only strange but inadequate about (...) these discussions being held apart. Particularly, I hold that by being held separately these discussions are philosophically incomplete. In this paper, I argue that these debates are parallel in crucial aspects, but more importantly that they can benefit from each other if they start a dialogue. I suggest some paths we can take to start fruitful discussions and offer examples of the kind of outcomes we can expect. However, my main contribution is to sketch a common framework to map current discussions, make comparisons between them, and, more importantly, guide new research. (shrink)

It is a mistake to think that any philosophical contribution to the study of psychopathology is otiose. I identify three non-exhaustive roles that philosophy can and does occupy in the study of mental disorder, which I call the agenda-setting role, the synthetic role, and the regulative role. The three roles are illustrated via consideration of the importance of Jaspers’ notion of understanding and its application to specific examples of mental disorder, including delusions of reference, Capgras delusion and other monothematic delusions, (...) and clinical depression. Together the three roles assign to philosophy of psychopathology the task of determining how to situate the varieties of mental disorder within the system of interpretive and evaluative concepts that partially make up the dynamic but indispensable manifest image. (shrink)

In this article, I explore Seth Farber’s critique in _The Spiritual Gift of Madness_ that the leaders of the Mad Pride movement are failing to realize his vision of the mad as spiritual vanguard of sociopolitical transformation. First, I show how, contra Farber’s polemic, several postmodern theorists are well suited for this leadership (especially the Argentinian post-Marxist philosopher Ernesto Laclau). Second, I reinterpret the first book by the Icarus Project, _Navigating the Space between Brilliance and Madness_, by reimagining its central (...) metaphor of Icarus in the context of late capitalism as a prison world. Finally, I conclude with four strategies derived therefrom for higher functioning mad leaders to transform our penitentiary world. (shrink)

In this paper, I draw on phenomenological analyses of religious voice-hearing and related experiences to elucidate the role of phenomenology in discerning benign from pathological religious experience. First, I present phenomenological discontinuities between cases of benign and pathological voice-hearing by drawing on a study of first-person accounts of voice-hearers within the Pentecostal movement which evinces that voice-hearing is not inherently pathological. Second, I introduce the epidemiological continuity of psychotic-like phenomena by drawing on a study of the contextual and responsive differences (...) between clinical and non-clinical voice-hearers which point to the contexts wherein voice-hearing does not lead to pathology. Third, I present a successful case where the meaning of the anomalous experiences is validated and normalized by drawing on studies of mediumistic experience which illuminate its therapeutic benefits. Finally, I argue that failing to take the voice-hearer’s lived experience into account in the diagnostic moment can result in the pathologization of benign experiences. (shrink)

Le controversie nosologiche in psichiatria siano orientate da ragioni sia epistemiche che non epistemiche, da questioni di evidenza ma anche di etica e sociologia della scienza, data la presenza di vari programmi di ricerca, di metodologie e anche di agenti differenti che si focalizzano sul problema del disturbo mentale. I due casi qui brevemente considerati, quello della Disposofobia e quello del Disturbo di personalità narcisistica mostrano, assieme al ruolo dell’evidenza empirica, da un lato il peso delle ragioni etiche dei gruppi (...) di pazienti e di quelle culturali della società allargata, dall’altro le dinamiche del consenso tra esperti. Che i disturbi mentali siano o non siano generi naturali, la loro classificazione è un processo razionale complesso che comprende norme e deviazioni dalle norme di diverso tipo. (shrink)

Literature on epistemic injustice has grown tremendously as an increasingly rich and diverse body of work in recent years. From the point of view of intercultural and anticolonial discussions, contemporary contributions have also helped to illuminate how epistemic injustice and other forms of cultural domination might be related to essential processes within the structures of colonial and racial supremacy. -/- This proposal aims to contribute to such relevant and illuminating discussions by focusing on the role that language and culture might (...) have in phenomena of epistemic injustice, particularly, hermeneutical injustice. Despite the central role played by semantics in epistemic injustice studies, the question about whether certain languages could also themselves be the recipients of epistemic injustice has been rather undertheorized. Simultaneously, recent movements to advocate for minority language rights, such as the Linguistic Human Rights Movement (LHR), raise important questions in this connection. -/- In the present paper, I argue that attending to the intercultural context reveals a new sort of hermeneutical injustice, one that, surprisingly, has never been articulated before. In particular, I am referring to a kind of HI that is essentially “linguistic” and “culture-specific”. I will be presenting two different subtypes for this kind of hermeneutical injustice: The first concerns the possibility of considering certain languages themselves as genuine objects of hermeneutical injustice,while the second has to do with certain specific culturally-established expressions or forms of talking. (shrink)

This paper provides a historical analysis of a shift in the way animal models of mental disorders were conceptualized: the shift from the mid-twentieth-century view, adopted by some, that animal models model syndromes classified in manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), to the later widespread view that animal models model component parts of psychiatric syndromes. I argue that in the middle of the twentieth century the attempt to maximize the face validity of animal models (...) sometimes led to the pursuit of the ideal of an animal model that represented a behaviorally defined psychiatric syndrome as described in manuals such as the DSM. I show how developments within psychiatric genetics and related criticism of the DSM in the 1990s and 2000s led to the rejection of this ideal and how researchers in the first decade of the twenty-first century came to believe that animal models of mental disorders should model component parts of mental disorders, adopting a so-called endophenotype approach. (shrink)

Paperwork plays a key role in a how institutions accommodate, refuse, or manage disabled people. This article develops modes for reading paperwork that build on each other, beginning with (a) recognizing the institutional pressures at work in shaping bureaucratic practices, then (b) considering how a person's relationship to disability influences how they might encounter these practices, and ultimately (c) noticing how the encounter between disabled/mad people and an institution might create something new, what the author calls archival excess. These methods (...) for reading are in conversation with disability studies, medical humanities, and document studies, and ultimately work toward a goal adapted from the principles of Disability Justice: recognizing the wholeness of disabled subjects in institutional archives. (shrink)

The mid-century object relations approach saw the category of schizoids as crucial to its own formation. Rooted in a developmental phase where the perception of the mother as a whole and real person had not yet been secured, the schizoid constitution impeded relationships and forced schizoids to communicate through a compliant persona while the kernel self remained isolated. Fairbairn, Winnicott, and Guntrip thought that schizoid features underlay many other pathologies that earlier, Freudian psychoanalysis had misidentified. To correct this, a move (...) to the attachment-oriented theory was necessary, triggering the development of the object relations perspective as a distinct and independent approach. While playing this role in the development of object relations theory, the schizoid category also attracted a note of disapproval. Fairbairn, Winnicott, and Guntrip described schizoids as harmful to society through their everyday actions and through the ideas they propagated. This judgemental nuance highlights an aspect of the alliance between object relations theory and the contemporary welfare state ideology. Culminating in the Beveridge plan, that ideology framed citizenship as comprehensive engagement with society on multiple levels. Citizenship was not just a political activity but also a personally rewarding one, as it allowed expression to each person’s wishes in ways that benefited others. Inability to engage and be rewarded in this way marked obstinate classes and produced rigid and conservative ideologies that opposed the welfare state. Object relations theory described the schizoid condition along similar lines and castigated its consequences for similar reasons. (shrink)

Realists about mental disorder have been hasty about dismissing social explanations of how mental disorder is constituted. However, many social ontologies are realist ontologies. In order to create a meaningful distinction between realism and social metaphysics about mental disorder, I propose that realism about mental disorder is best understood as Individual Trait Realism (ITR) about them. For ITR, mental disorders exist in virtue of traits. I defend the view that ITR is compatible with social metaphysics, arguing that, in asking whether (...) constituents in the social sphere figure the metaphysics of psychopathology, we are asking questions on three different strata of explanation: the strata of demarcation, instantiation, and individual traits. Distinguishing between these strata allows for nuanced realism that need not reject the social constitution of mental disorder. (shrink)

This paper contributes to the debate in the philosophy of psychiatry regarding the relation between thought insertion in schizophrenia and the sense of selfhood. Some scholars have suggested that thought insertion presents a case where the sense of selfhood is lacking. Other scholars have disputed this by proposing that a form of minimal selfhood is a necessary feature of consciousness that is still present in thought insertion, albeit in a disturbed manner. Herein, I argue that the notion of minimal selfhood (...) that is used by these scholars is ambiguous between two meanings. The first is an ontological notion concerning the first-person individuation of consciousness. The second is a phenomenological notion concerning how a conscious experience is experienced as being given to the first-person subject. I argue that the former ontological notion is indeed a necessary feature of conscious experience, but the latter phenomenological notion is only a contingent feature. Therefore, even if it is possible that thought insertion presents a case where the feeling of first-person givenness is lacking or disturbed, the first-person individuation of consciousness remains present and undisturbed. As well as further clarifying the connection between consciousness and selfhood, this philosophical analysis reveals the extent to which schizophrenia can and cannot be said to comprise a disorder of selfhood. (shrink)

Introduction to The Oxford Handbook of Phenomenological Psychopathology.

In this chapter, I introduce phenomenology and phenomenological psychopathology by clarifying the kind of implicit experiences that phenomenologists are concerned with. In section one, I introduce the phenomenological concept of pre-reflective experience, focusing especially on its relation to the concept of implicit experience. In section two, I introduce the structure of pre-reflective self-consciousness, which has been studied extensively by both classical phenomenologists and contemporary phenomenological psychopathologists. In section three, I show how phenomenological psychopathologists rely on an account of pre-reflective self-consciousness (...) to better understand the experience of schizophrenia and I outline some of the methodological challenges that arise in this field of research. This introduction should facilitate critical engagement and collaboration between phenomenologists and researchers working across a variety of disciplines, including psychology, psychiatry, the cognitive sciences, and analytic philosophy of mind. (shrink)

The Heythrop Journal, Volume 63, Issue 2, Page 315-316, March 2022.

Our main objective is to locate and analyze some philosophical issues about the concept of mental illness and the manner it is used, especially in contemporary psychiatry. It is even difficult to find a standard meaning in the main psychiatric textbooks; and, when there is some exposition of the concept, it is sparse, uncritical and vague. As an immediate consequence of these issues, practical guidelines and protocols for the clinic arise, which become almost “automatic”, unreflective behaviors, practices translated as health (...) interventions and public mental health policies. An example is the problem of overdiagnosis, in which the use of medical technology (categories, drugs, clinical exams, etc.) has generated more harm and risks to the subject's health than benefits. Exposing these issues from a philosophical perspective can eventually contribute to the field of mental health. For this work, the main manuals and textbooks of psychiatry were selected to analyze how they deal with the concept of mental illness or disorder, in addition to locating the present discussion in authors from both philosophy and the psychiatric field and how they contribute to its clarification. (shrink)

The professional application of ethics often lacks the necessary conceptual tools to construct adequate theoretical foundations that can be used for practical enterprise. This book focuses on an anthropological approach to mental illness, describing how schizophrenia can distort one's experience of empathy and of the presence in the world through pathological indifference. It describes factual and phenomenological perspectives on a case of schizophrenia, based on the method of Eugène Minkowski.

This thesis develops a novel framework for explaining delusions. In Chapter 1, I introduce the two fundamental challenges posed by delusions: the evidence challenge lies in explaining the flagrant ways delusions flout evidence; and the specificity challenge lies in explaining the fact that patients’ delusions are often about a few specific themes, and patients rarely have a wide range of delusional or odd beliefs. In Chapter 2, I discuss the strengths and weaknesses of current theories of delusions, which typically appeal (...) to one or both of two factors: anomalous experience and reasoning abnormality. I argue that anomalous experience can help explain the specificity of delusions, but has difficulties in addressing the evidence challenge; reasoning abnormality can help address the evidence challenge, but has difficulties in explaining the specificity of delusions. This suggests that there may be an important factor that has not been captured by current theories of delusions. To search for this missing factor, in Chapter 3, I turn to normal believing. Inspired by the literature on Cartesian clarity and phenomenal dogmatism, I develop a dual-force framework of believing, according to which beliefs can be understood as the results of the interaction between the justificatory force and causal force of evidence and the justificatory force and causal force of clear experience, in which something clearly seems to be so to the subject. This framework suggests that the missing factor may be the clear experience with its distinctive phenomenal clarity that compels assent. In Chapter 4, I return to delusions, and argue that the dualforce framework can help us to get a better grip on some personal descriptions of delusions; make progress in addressing the evidence and specificity challenges of delusions; and shed new light on the underpinnings of delusions. In the end, I conclude with some remaining questions for future study. (shrink)

Currently, anomalous lived temporality is not included in the main diagnostic criteria or standard symptom checklists. In this article, we present the Transdiagnostic Assessment of Temporal Experience, a structured interview that can be used by researchers and clinicians without a comprehensive phenomenological background to explore abnormal time experiences in persons with abnormal mental conditions regardless of their diagnosis. When extensive data gathered by this scale are available, it will be possible to delineate well-defined anomalous lived temporality profiles for each psychopathological (...) disorder. This instrument may also prove useful for clinicians by providing a more refined assessment of relevant psychopathological symptoms and an in-depth understanding of the patient’s abnormal behaviour as related to specific types of time experience. In the first part of the article, we provide a brief overview of the phenomenological concept of temporality, including pre-phenomenal and phenomenal time, synthesis, conation and synchronization, and of abnormal time experiences in persons affected by psychopathological conditions. In the following part, we describe the basic structure of the interview that comprises seven categories corresponding to the abnormal features of lived temporality: anomalies of synchrony, of time structure, of implicit time flow, of explicit time flow, and anomalous experiences of the past, the present and the future. The paper also includes a section on administration and scoring of the TATE scale, the complete interview and a Likert table for quantifying the frequency, intensity and interference with daily life of the phenomena explored. (shrink)

Naturalistic accounts of mental disorder aim to identify an objective basis for attributions of mental disorder. This goal is important for demarcating genuine mental disorders from artificial or socially constructed disorders. The articulation of a demarcation criterion provides a means for assuring that attributions of 'mental disorder' are not merely pathologizing different forms of social deviance. The most influential naturalistic and hybrid definitions of mental disorder identify biological dysfunction as the objective basis of mental disorders: genuine mental...

In this paper I discuss Wakefield’s account of mental disorder as applied to the case of gender dysphoria (GD). I argue that despite being a hybrid account which brings together a naturalistic and normative element in order to avoid pathologising normal or expectable states, the theory alone is still not extensive enough to answer the question of whether GD should be classed as a disorder. I suggest that the hybrid account falls short in adequately investigating how the harm and dysfunction (...) in cases of GD relate to each other, and secondly that the question of why some dysfunction is disvalued and experienced as harmful requires further consideration. This masks further analysis of patients’ distress and results in an unhelpful overlap of two types of clinical patients within a diagnosis of GD; those with gender-role dysphoria and those with sex dysphoria. These two conditions can be associated with different harms and dysfunctions but Wakefield’s hybrid account does not have the tools to recognise this. This misunderstanding of the sources of dysfunction and harm in those diagnosed with GD risks ineffective treatment for patients and reinforcing the very same prejudiced norms which were conducive to the state being experienced as harmful in the first place. The theory needs to engage, to a surprising and so far unacknowledged extent, with sociological concepts such as the categorisation and stratification of groups in society and the mechanism of systemic oppression, in order to answer the question of whether GD should be classed as a mental disorder. Only then can it successfully avoid pathologising normal or expectable states, as has been seen in past ‘illnesses’ such as homosexuality and ‘drapetomania’. (shrink)

In this chapter we discuss the role of conscious and unconscious inference in theories of delusion formation. Two competing accounts aim to shed light on the formation of delusions: according to explanationism, the delusional belief is offered as an explanation for anomalous experience; according to the endorsement theory, the delusional belief is an acknowledgement that the anomalous experience is veridical. Whereas explanationists argue that the delusional belief is inferred from experience, endorsement theorists argue that there need be no inference from (...) the experience to the delusional belief. Here we put pressure on the idea that the two accounts can be distinguished on the basis of whether inference is involved in delusion formation and argue that they are both compatible with the increasingly influential idea that Bayesian inference is responsible for the adoption of the delusional belief. One of the models of delusion formation focusing on Bayesian inference is the Coltheart model (Coltheart, Menzies, and Sutton, 2010) which we discuss in detail in the chapter. We show that, given its features, the model does not fit neatly under either explanationism or the endorsement theory. (shrink)

Introduction to the book symposium “THE BIOPSYCHOSOCIAL MODEL OF HEALTH AND DISEASE: NEW PHILOSOPHICAL AND SCIENTIFIC DEVELOPMENTS BY DEREK BOLTON AND GRANT GILLETT”.

“The addict” is a well-known figure in philosophy, but analytical attempts to define “addictive disorder” are rare. According to extant views, the “hallmark” of addiction lies in an individual’s inability or impaired ability to control the behavior the individual is addicted to doing. But how exactly are we to understand the relevant concept of (in)ability (or impaired ability) in the first place? Furthermore, what else is necessary for an individual to have an addictive disorder? I argue for a definition of (...) “addictive disorder” in terms of desire, tolerance and withdrawal, inability, and harm. The main focus of this paper is on the concept of ability. The view I propose integrates insights from the literature on abilities and develops them further as they are relevant to addiction. The resulting view offers a more differentiated perspective on questions about what individuals with an addictive disorder can and cannot do. (shrink)

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders included the Social Communication Disorder as a new mental disorder characterized by deficits in pragmatic abilities. Although the introduction of SPCD in the psychiatry nosography depended on a variety of reasons—including bridging a nosological gap in the macro-category of Communication Disorders—in the last few years researchers have identified major issues in such revision. For instance, the symptomatology of SPCD is notably close to that of Autism Spectrum Disorder. This (...) opens up the possibility that individuals with very similar symptoms can be diagnosed differently and receive different clinical treatments and social support. The aim of this paper is to review recent debates on SPCD, particularly as regards its independence from ASD. In the first part, we outline the major aspects of the DSM-5 nosological revision involving ASD and SPCD. In the second part, we focus on the validity and reliability of SPCD. First, we analyze literature on three potential validators of SPCD, i.e., etiology, response to treatment, and measurability. Then, we turn to reliability issues connected with the introduction of the grandfather clause and the use of the concepts of spectrum and threshold in the definition of ASD. In the conclusion, we evaluate whether SPCD could play any role in contemporary psychiatry other than that of an independent mental disorder and discuss the role that non-epistemic factors could play in the delineation of the future psychiatry nosography. (shrink)

Major Depressive Disorder (MDD) is a serious condition with a large disease burden. It is often claimed that MDD is a “brain disease.” What would it mean for MDD to be a brain disease? I argue that the best interpretation of this claim is as offering a substantive empirical hypothesis about the causes of the syndrome of depression. This syndrome-causal conception of disease, combined with the idea that MDD is a disease of the brain, commits the brain disease conception of (...) MDD to the claim that brain dysfunction causes the symptoms of MDD. I argue that this consequence of the brain disease conception of MDD is false. It incorrectly rules out genuine instances of content-sensitive causation between adverse conditions in the world and the characteristic symptoms of MDD. Empirical evidence shows that the major causes of depression are genuinely psychological causes of the symptoms of MDD. This rules out, in many cases, the “brute” causation required by the brain disease conception. The existence of cases of MDD with non-brute causes supports the reinstatement of the old nosological distinction between endogenous and exogenous depression. (shrink)

Prosper Lucas (1808–1885) is a unique figure in the history of psychiatric genetics. A physician-alienist, he authored one of the most important books on human genetics in the mid-19th century cited frequently by Darwin: the 1,500 page treatise—Philosophical and Physiological Treatise on Natural Heredity (1847–1850). This book contained a novel theory of the nature of inheritance and a detailed review of the heredity of a range of human traits and disorders, including various forms of insanity. Lucas postulated four forms of (...) heredity (direct, crossed, indirect, and atavistic), supported the importance of hereditary factors in insanity, accepted the inheritance of acquired characteristics, considered it important to examine both ancestors and collateral relatives, and recognized that heredity could influence both primary insanity and insanity secondary to other medical conditions. He reviewed the then available literature on most major forms of insanity including separate sections on hallucinations and suicidal monomania. The literature consisted of case reports of unusual families with high concentrations of illness. Lucas advocated for the homogeneity of transmission of forms of illness in families but recognized that—just as the form of illness could evolve within individuals over time—it could change forms when transmitted between relatives. (shrink)

When interacting with other people, we assume that they have their reasons for what they do and believe, and experience recognizable feelings and emotions. When people act from weakness of will or are otherwise irrational, what they do can still be comprehensible to us, since we know what it is like to fall for temptation and act against one’s better judgment. Still, when someone’s experiences, feelings and way of thinking is vastly different from our own, understanding them becomes increasingly difficult. (...) Delusions and psychosis are often seen as marking the end of intelligibility. In this paper, I argue first for the importance of seeing other people as intelligible as long as this is at all possible. Second, I argue, based on both previous literature and my own lived experience, that more psychotic phenomena than previously thought can be rendered at least somewhat intelligible. Besides bizarre experiences like illusions, hallucinations and intense feelings of significance, I also explain what it is like to lose one’s bedrock, and how this loss impacts which beliefs one has reason to reject. Finally, I give an inside account of some disturbances of reason, and show that there are important similarities between certain psychotic reasoning problems and common non-pathological phenomena. (shrink)

Summary Background Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, service users’ views on self-binding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, and human (...) rights. Methods This study used qualitative data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision-making in bipolar disorder. Quantitative analysis of a closed question about self-binding directives had already demonstrated endorsement amongst a very high proportion of participants with bipolar disorder who completed the survey. We conducted thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was co-produced within a multi-disciplinary team, with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methodologies associated with all these areas of expertise were used in the analysis of these reasons and to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues. Findings Between Oct 23 and Dec 5, 2017, 932 individuals with a self-reported clinical diagnosis of bipolar disorder completed the internet survey, with 565 (154 men; 400 women; 11 transgender or other) providing free text answers to the open question. A large majority of respondents endorsed self-binding directives, nearly all describing a determinate shift to types of distorted thinking and decision-making when unwell as their key justification. Responses indicating ambivalence were dominated by logistical concerns about the drafting and implementation of self-binding directives, while those who rejected self-binding directives also cited logistical concerns, validity of their thinking when unwell, and potential contravention of human rights. Interpretation This study is, to our knowledge, the first large study of reasons why mental health service users might endorse or reject the use of self-binding directives. The findings provide empirical support for introducing self-binding directives into mental health advance decision-making practice and policy and may help to address enduring ethical concerns surrounding possible implementation of the directive while a person retains decision-making capacity. The opinions expressed here in responses given by multiple service users with bipolar disorder challenge a prominent view within international disability rights debates that involuntary treatment and recognition of impaired mental capacity constitute inherent human rights violations. Funding The Wellcome Trust . (shrink)